The Sustainable Management of Healthcare Waste

Introduction
Elements of Sustainable HCW Management
The Importance of Regulation
Choosing HCWM Facilities
International Regulation
Disposal of HCW
References
Further Reading

Healthcare waste management (HCWM) has become a major challenge as healthcare becomes more sophisticated, population size increases and healthcare facilities expand. All these factors demand the use of more equipment and consumables, much of which ends up as healthcare waste (HCW).

The World Health Organization (WHO) classifies biomedical waste (BMW) as number 2 on the list of hazardous wastes, necessitating strict disposal policies which must be enforced by hospitals and waste treatment units in unison, to prevent contamination and pollution of the hospital surroundings. While China, which makes up over a seventh of the world’s people, contributed about 700 million kg of HCW in 2005, the USA, with its advanced healthcare systems, produced over 3 billion kg!

HCW comprises several categories (infectious, pathological – toxic, radioactive, corrosive, or reactive – pharmaceutical, and chemical waste, as well as sharp objects), making segregation essential for, at least:

• Sharps
• High-risk HCW
• Low-risk HCW
• General waste including recyclable waste

While up to 90% is composed of general waste, up to a quarter may be considered hazardous.

Elements of sustainable HCW management

To dispose of healthcare waste in a sustainable manner, proper policies need to be framed, infrastructure set up and the rational use of medical equipment encouraged. The four principles of sustainability in managing HCW include the use of technology that is:

• environmentally safe and does not harm public health
• cost-effective and disposes of the waste in accordance with its economic value
• socially acceptable and equitable to all local communities
• supervised meaningfully and consistently to ensure that sound environmental measures are followed over the long term.

The aims of sustainable HCWM thus include reducing the consumption of natural resources through reuse, recycling and recovering the materials before they have to be disposed of, and disposing of such waste with minimal environmental impact.

Some ways to prevent unnecessary waste include:

• Reduce:
  • Reduce packaging and shipping waste as well as wastage of expired products by “just in time” inventory management
  • Prohibit the procurement of materials with toxic substances; reduce or eliminate waste by, for instance, using digital instead of physical medical records, thus avoiding unnecessary duplication of tests and orders
  • Changing over to digital X-ray systems and thus avoiding hazardous chemicals and exposures and wastes produced by analog X-ray systems
• Reuse
  • Use reusable items such as washable glass or ceramic cups and thermometer probes
  • Keep items that can be reused in good order, cleaned and refurbished if required
  • Prepare those that are little used or unused for reuse
• Recycle
  • Use recycling-friendly materials where contamination is not a possibility
  • Recycle materials wherever possible
  • Use organic components to produce biofuels or other chemicals with saleable value

Energy recovery is also possible in some cases, as up to 99% of the waste can be incinerated, producing heat, 80% of which can be captured in a heat recovery system. The biofuel generated from the pyrolysis of HCW was estimated to contain up to 94% synthetic gas, bio-oil and bio-char up to 6%, with the cycle efficiency being <20%.

Where these steps have been carried out, or are not possible, the aim should be to sterilize infectious waste so it can be safely disposed of. Disposal, either in landfills or by incineration without recovering energy, is the most wasteful and least desirable means of HCWM.

The importance of regulation

Unregulated HCWM can result in waves of disease, including anthrax, respiratory infections, gastroenteritis, genital and skin infections, and multiple viral infections such as viral hepatitis, acquired immunodeficiency syndrome (AIDS) and hemorrhagic fevers. It can pollute the environment, and exacerbate climate change.

Efficient and robust waste management regulatory systems are essential to ensure a sustainable pattern of HCWM.  This involves legislation on the definition and classification of HCW, and the monitoring and enforcement of HCWM, to avoid the illegal dumping of un-segregated waste, uncontrolled processing and uncontrolled emissions. Such policies must set targets and timelines for treating and disposing of HCW at basic levels, in every healthcare center; set up financial assistance schemes for the purpose; and introduce enforcement strategies, at least.

Several challenges have been identified in HCWM, including budgetary allocations, evolving and enforcing HCW segregation at the point of production to keep infectious waste separate and thus conserve the resources needed for their safe disposal; sanitary safe transport of HCW; educating HCW workers to protect themselves while safely and correctly disposing of waste; and finding sustainable ways of waste disposal.

In many countries, hospitals may outsource HCWM without ensuring that the contractor is actually capable of and has a good record in following relevant government policies and environmental regulations. This shows poor regulatory oversight, allowing profit motives to override responsible decision-making.

Choosing HCWM facilities

The “most strategic decision in any healthcare institution”, namely, selecting an HCWM partner, is facilitated by documentation and audit trails, that help determine the contractor’s compliance with environmental regulations and hygiene standards. This will also reduce processing costs.

Technology and qualification criteria are crucial to such documentation, including tracking technology on HCW-loaded trucks and bags containing individual waste categories of waste, as well as greener disposal technologies. Cost analysis is also important, in permitting financially viable operations that are rewarding for all stakeholders.

International regulation

Many international conventions are in force to deal with HCWM in one or more aspects. These include the Basel Convention on waste management, the Rotterdam Convention for international cooperation in waste management, the Aarhus Convention providing information access and participation in environmental policy for the public and the Stockholm Convention on Persistent Organic Pollutants.

The latter underlined the importance of using the best available technology (BAT) and best environmental practices (BEP) to reduce the production of environmentally persistent pollutants like polychlorinated dibenzo-para-dioxins (PCDD) and polychlorinated dibenzofurans (PCDF) as a result of incineration.

Disposal of HCW

Incineration of HCW has been the preferred option in most countries. Not only is it universally applicable, but it neutralizes infective particles in medical waste, thus ending a major component of their hazardous nature. It requires, however, a strict separation of infectious waste to avoid the emission of unnecessarily large amounts of toxic vapors from plastic components.

Flue gases from incineration processes of HW need to be monitored and treated for the removal of toxic and pollutant substances. The residual ash must be disposed of safely or must be recycled, as in certain types of mortar mixes like calcium aluminate cement (CAC) mortars.

Advanced incinerator technology is available, such as fixed and fluidized bed incinerators, rotary kilns, or incinerators run on biofuels rather than fossil fuels. However, the higher costs of upgrading incineration plants, whether to build, run, maintain or supervise their operation, is often a limitation in developing countries, especially those with a large population and a large healthcare facility network.

For this reason, it is important to keep the generation of medical waste to a minimum. This will partner with the global drive to reduce the emissions of noxious wastes into the atmosphere.

Alternatives to incineration besides the landfill are also available, including microwave treatment, steam sterilization, advanced steam sterilization, dry heat sterilization, alkaline hydrolysis and biological treatment. Ozone, ultraviolet irradiation, chlorine and chlorine-generating chemicals are also being used.

These are now considered preferred options, for many reasons.

Firstly, many older incinerators no longer fulfill environmental norms. Their upgrading would incur significant costs, suggesting the benefit of building an alternatively-powered disposal unit.

Secondly, the need for state-of-the-art air pollution monitoring and control systems would be unsustainable for smaller incineration plants.

Thirdly, public opinion has turned against incineration, which favors the approval of other technologies. New incineration sites are constrained, both in terms of cost and social acceptance.

As a result, the switch to less expensive, easy to maintain, alternative technologies that do not produce toxic wastes, especially PCDDs and PCDFs, maybe more natural in low-income countries, while in developed countries it is already in force. Novel strategies are being explored, including electricity generation from HCW and anaerobic digestion.   

References

• Technical Brief: Sustainable Health Care. Waste Management. (2020). https://www.theglobalfund.org/media/9356/core_healthcarewastemanagement_technicalbrief_en.pdf. Accessed on June 24, 2022.
• Yang, C. et al. (2009). Sustainable Management Measures for Healthcare Waste in China. Waste Management. https://doi.org/10.1016%2Fj.wasman.2008.11.031. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7126051/. Accessed on June 24, 2022.
• Thakur, V. et al. (2020). Managing Healthcare Waste for Sustainable Environmental Development: A Hybrid Decision Approach. Business Strategy and the Environment. https://doi.org/10.1002/bse.2625. https://onlinelibrary.wiley.com/doi/10.1002/bse.2625. Accessed on June 24, 2022.
• Hassan, M. F. et al. (2018). Recent Developments in Sustainable Management of Healthcare Waste and Treatment Technologies. Journal of Sustainable Development of Energy, Water and Environment Systems. http://dx.doi.org/10.13044/j.sdewes.d9.0384. http://www.sdewes.org/jsdewes/pid9.0384. Accessed on June 24, 2022.

Further Reading

• All Healthcare Content
• Healthcare Systems Around the World
• What is the Role of Regulatory Bodies in Healthcare?
• How is the ‘omics’ Revolution Changing Healthcare?
• Primary Healthcare Providers

Written by

Dr. Liji Thomas

Dr. Liji Thomas is an OB-GYN, who graduated from the Government Medical College, University of Calicut, Kerala, in 2001. Liji practiced as a full-time consultant in obstetrics/gynecology in a private hospital for a few years following her graduation. She has counseled hundreds of patients facing issues from pregnancy-related problems and infertility, and has been in charge of over 2,000 deliveries, striving always to achieve a normal delivery rather than operative.